[Diagnostic yield of abdominal ultrasonography in acute appendicitis]. / Rendimiento de la ecografía abdominal en el diagnóstico de apendicitis aguda.

INTRODUCTION: Acute appendicitis (AA) is the first cause of surgical abdomen in childhood but diagnosis continues to be difficult in some cases. Abdominal ultrasonography has been shown to be useful when there is doubt about the diagnosis and can be quickly and easily performed at the patient's bedside. OBJECTIVE: To evaluate the efficacy of abdominal ultrasonography in the diagnosis of acute appendicitis in our hospital. PATIENTS AND METHODS: All patients who visited the emergency department for abdominal pain and who underwent abdominal ultrasonography to rule out AA between January 1, 1999 and December 31, 2000 were retrospectively studied. RESULTS: During the study period, 4217 children were evaluated in our service for abdominal pain. Ultrasonography was performed in 528 children. Of these, the procedure was performed to rule out AA in 308 patients. Of these 308 patients who met the study's inclusion criteria, the results of ultrasonography were compatible with AA in 102 and were normal in 196. Ultrasonographic diagnosis differed from the final diagnosis in 16 patients. In eight children with ultrasonographic findings suggestive of AA, laparotomy revealed normal appendices. In the remaining eight patients, ultrasonographic findings were normal and surgery revealed AA. Based on these findings, the diagnostic yield of abdominal ultrasonography was: sensitivity: 96.6 %; specificity: 95.9 %, positive predictive value: 86 %; negative predictive value: 95.9 %. CONCLUSIONS: The overall diagnostic yield of abdominal ultrasonography in AA our hospital is acceptable. Because ultrasonographic diagnosis is not always accurate, others diagnostic methods such as computed tomography should be used in doubtful cases.

[Emergency department visits for poisoning: epidemiological changes in the last 10 years]. / Intoxicaciones en urgencias: cambios epidemiológicos en los últimos 10 años.

OBJECTIVE: To study the epidemiological changes observed in pediatric poisonings treated in our Emergency Department between 1988 and 1999. PATIENTS AND METHODS: Descriptive, observational study performed in three 12-month periods (1988, 1993 and 1999). The circumstances surrounding the visit, treatment in the Emergency Department and clinical evolution were registered. RESULTS: Consultations for possible poisoning decreased between 1988 and 1999 (279 vs. 161, p 0). This decrease was noted both in poisonings caused by household products (91 vs. 48, -47 %) and those caused by drugs (112 vs. 87, -22 %). Antipyretics caused one-third of drug poisonings and psychotropics caused approximately 11 %. The most commonly implicated agent is currently paracetamol. Caustic alkali were the most common household products causing poisoning although the number of such poisonings decreased (48 episodes in 1988 and 18 in 1999). Hydrocarbons were the second most frequent cause of household product poisoning (12-16/year). Most episodes occurred at home. The poison, mainly household products, was kept in a container other than the original in nearly 5 % of episodes in 1988 and in 13.7 % in 1999. The number of children receiving treatment in the Emergency Department decreased between 1988 and 1993 and remained stable between 1993 and 1999 (62 % in 1988 and approximately 35 % in 1993 and 1999; p 0.000003). The number of admissions also decreased from 17 children in 1989 (6.0 %) to six in 1999 (3.7 %, p 0.39). No deaths were recorded. CONCLUSIONS: In the last ten years, visits for possible episodes of pediatric poisoning have decreased, mainly those due to mild poisoning caused by household products. Paracetamol has replaced acetyl-salicylic acid as the most frequently implicated drug.

[Use of a hospital pediatric emergency department during the night]. / Utilización nocturna de una unidad de urgencias pediátrica hospitalaria.

OBJECTIVE: To determine the characteristics of children younger than 14 years visiting our pediatric emergency department between 0:00 and 8:00 hours. PATIENTS AND METHODS: Retrospective review of 300 children visiting our emergency department at night. RESULTS: Between March 1 and 22 1999 we recorded 300 episodes from 0:00-8:00 hours (1.7 patients/hour) and 2350 episodes from 8:00-24:00 hours (6. 6 patients/hour). Of the 300 episodes registered at night, 132 children (44%) came between 0:00 and 2:00. The most common complaints were: respiratory symptoms in 116 patients (38.6%), fever in 61 (20.3%) and digestive symptoms in 61 (20.3%). We carried out at least one complementary test in 111 patients (37.0%). Five children (1.7%) were admitted to the hospital (80 between 8:00 and 24:00, 3.4%, p = 0.15) and 25 (8.3%) were admitted for a few hours to the observation ward (123 of the 2350 who came between 8:00 and 24:00, 5.2%, p = 0.06). Final diagnoses were: ear nose and throat infection in 91 (30.3%), fever without source in 38 (12.6%), asthma in 29 (9.6%), acute gastroenteritis in 27 (9%), croup in 22 (7.3%), vomiting in 14 (4.6%), abdominal pain in 13 (4.3%), febrile convulsion in 6 (2%), pneumonia in 5 (1.6%), bronchiolitis in 5 (1. 6%), bacteremia in 1 (0.3%), and other diagnoses in 46 (16.3%). CONCLUSIONS: The number of visits to our emergency department diminished at night, particularly between 0:00 and 2:00. The night-time admission rate was less than the daytime rate, although this difference was not statistically significant. Admission for a few hours to the observation ward was more common at night. The percentage of patients with respiratory illnesses was higher during the night.

[Children's unscheduled return visits to an emergency department]. / Los niños que repiten consulta en urgencias de pediatría.

OBJECTIVE: To study the patients who make unscheduled return vi-sits in less than week to a pediatric emergency department (ED). PATIENTS AND METHOD: Retrospective review of 495 episodes in 233 children who were attended at our ED in November 1999. RESULTS: In November 1999, we registered 3667 episodes at our ED (495 corresponding to 233 children who made repeat visits, 13.4%). The most common chief complaints among children who revisited were fever and respiratory symptoms. The most common diagnoses were fever with-out apparent source, ORL infections, asthma and acute gastro-enteritis. The diagnoses made at the initial and fi-nal visits were the same in 131 cases (56.2%), a complication was detected in 18 (7.7%) and 84 (36.1%) were given a different diagnosis. The percentage of patients who received a symptomatic diagnosis was lower in the final visit. The admission rate of children who revisited was higher than that of children who visited our ED once (6.4% vs. 3.0%, p = 0.009), caused by the group of patients who received a different diagnosis when they revisited our ED. CONCLUSIONS: Patients who revisit a pediatric ED within a week are more likely to be admitted to the hospital, especially if the diagnosis they receive varies.

[Outpatient management of children with viral meningitis]. / Tratamiento extrahospitalario de los niños con meningitis viral.

OBJECTIVE: To describe our experience in the extrahospitalary management of children with suspected viral meningitis (YM). METHOD: Between April and July 1997. 156 children were diagnosed of YM in our hospital and 150 managed as outpatients, after being a few hours in our emergency department. All of them were suspected to have VM attending usual clinical and laboratory findings and were discharged with cautious instructions to demand a new assessment. We contacted telephonically with them one month and six months later. RESULTS: All the children with suspected viral meningitis and managed as outpatients had negative blood and CSF cultures and all of them did well. Telephonically, 104 children (69.3%) referred transient headache or back pain. and 20 of these (13.3% of all the 150) came again to our hospital, and 4 required rest for a few hours (4-12 hours) in our observation setting. Children with suspected VM didn't go to school during 5.9 x 6.1 days (1-30 days) and 71 (47.3%) were absent less than 3 days. CONCLUSION: Outpatient management of most of the children with suspected VM is possible. When a patient is sent home, detailed instructions must be given to the family.

[Lumbar puncture in a pediatric emergency department: something more than a diagnostic technic]. / Punción lumbar en Urgencias de Pediatría: algo más que una técnica diagnóstica.

OBJECTIVE: The aim of this study was to know the incidence of serious bacterial infections (SBI) in children without sepsis or intracranial infection in which spinal puncture (LP) was performed in an Emergency Department. PATIENTS AND METHODS: A retrospective study of all 471 previously healthy children between 1 month and 14 years of age in which a lumbar puncture was performed between July 1995 and March 1997 in the Emergency Department of our hospital was performed. RESULTS: Two hundred and three children (43%) had sepsis, meningitis or encephalitis (aseptic meningitis 149, 31.6%; sepsis-bacterial meningitis 26, 5.5%; nonspecific meningitis 26, 5.5%; encephalitis 2, 0.4%) and 14 (5.2%) had pneumonia. Of the other 254 children, 36 (14.1%) had a SBI: 19 urinary tract infections (E. coli), 11 bacteremia (Streptococcus pneumoniae 8, Salmonella enteritidis 1, Proteus mirabilis 1, E. coli 1, the latter two also having a positive urine culture) and 6 bacterial gastroenteritis (salmonella 5, Campylobacter jejuni 1). The incidence of SBI was significantly higher in the group of children younger than 5 years old (32/175, 18.2%) than in the older group (4/79, 5.0%, p = 0.009). Two patients died (one with pneumococcal meningitis and one with meningococcal sepsis). CONCLUSIONS: Children with fever and a normal result in the LP must be carefully examined and, especially in younger patients, urine, blood and stool (if stool abnormalities) cultures should be collected. These children must be closely observed in the hospital or at home and must be re-evaluated by their pediatrician in the following 24 hours.

[Diagnostic value of reactive C protein in suspected acute appendicitis in children]. / Valor diagnóstico de la proteína C reactiva en las sospechas de apendicitis aguda en la infancia.

OBJECTIVE: The aim of this study was to evaluate the accuracy of C-reactive protein (CRP) measurements in the diagnosis of suspected acute appendicitis (AA) during childhood. PATIENTS AND METHODS: A prospective study of 195 consecutive children, aged between 2 and 14 years and suspected of having AA, that attended a pediatric emergency room was carried out. We obtained a careful patient history, physical signs, blood test results, final diagnosis and the histological findings in the cases who underwent appendectomy (classified as normal appendix, simple appendicitis (SA) or gangrenous appendicitis (GA). RESULTS: The final diagnoses and their frequencies were: AA (94), non-specific abdominal pain (80), mesenteric lymphadenitis (6) and others (15). Appendectomies were performed in 103 cases with 94 cases being AA (91.3%) and of these 51 SA and 43 GA. The average values of CRP (mg/l) were: AA: 30, SA: 16, GA: 67, non-specific abdominal pain: 15, and mesenteric lymphadenitis: 44 (p < 0.01). The values of AG were statistically higher than those of SA (p = 0.0000). The ROC curve of these data determined the best cut-off levels for AA to be 30 (sensitivity: 0.43, specificity: 0.92, predictive value of a positive result: 0.87 and predictive value of a negative result: 0.58). CONCLUSIONS: 1) The value of CRP in AA is higher than in other abdominal pain etiologies. Nevertheless, this value should not be used to deny surgery since it is often normal in SA. 2) When a CRP value > 40 mg/L is found in a suspected AA, one should think about GA and therefore, initiate prophylactic antibiotics and perform surgery immediately.

[Clinical and epidemiological spectrum of Mycoplasma pneumoniae infections at a pediatric hospital]. / Espectro clínico-epidemiológico de las infecciones por Mycoplasma pneumoniae en un hospital infantil.

OBJECTIVE: The objective of this study was to determine the epidemiology of Mycoplasma pneumoniae infections at our hospital and to evaluate the prescription of macrolides to empirically treat respiratory infections in children. PATIENTS AND METHODS: A one year prospective study was performed. To find out the prevalence of M. pneumoniae infections, we obtained blood samples of 519 children attending our hospital out-patient department to determine M. pneumoniae IgG levels. In order to establish the incidence, IgM antibodies against M. pneumoniae were measured in 255 children admitted to the hospital showing clinical pictures compatible with this infection. RESULTS: In the first years of life, prevalence of M. pneumoniae infection was low. According to our study, only 3.3% of 1 year-old patients had M. pneumoniae antibodies. Antibody levels increased in children of 5 years or older. The highest rates, between 58.5% and 63.3%, were detected in patients between 8 and 12 years of age. The incidence rate (6.7%) was low among the children admitted. The most frequent clinical entity was pneumonia (82%). The highest rate of infection was found in children of 8 to 10 years. Symtomatology was mainly sub-acute. Crioagglutinins provided the most significant predictive value for etiological diagnosis. CONCLUSIONS: M. pneumoniae infections gain significance in patients over 5 years of age. In our environment, incidence of acute symptomatic infection is low. We consider that both age and presentation of acute respiratory processes should be taken into account when establishing empirical macrolide treatment in children.

[Recent changes in emergency room visits and hospitalization for asthma in childhood]. / Cambios recientes en la frecuentación a urgencias y hospitalización por asma en la infancia.

OBJECTIVE: The purpose of this study was to investigate recent changes in the emergency room visits and hospital admission rates between 1993 and 1997 in our hospital. PATIENTS AND METHODS: From January 1, 1993 until December 31, 1997, the 12,848 patients between 0 and 14 years of age whose discharge diagnosis was coded as asthma (ICD9) and who were managed in the emergency room of our hospital were included in the study. RESULTS: During the study period, the number of emergency room visits for asthma (EA) remained unchanged. However, in children between 0 and 5 years of age the number of EA showed a significant increase from 1305 in 1993 (53.5% of all EA) to 1849 in 1997 (68.9% of EA), with an increase of the repeat visits in this age group from 46 (35.8% of all EA in this age group) in 1993 to 791 (42.8%) in 1997 (p < 0.01). In the same period of time, the admission rates for asthma decrease from 7.2% to 2.9% (p < 0.01). There was a trend towards more intense treatment of asthma in the emergency observation unit. CONCLUSIONS: There has been an upward trend in the number of acute asthma episodes between 1993 and 1997 in children between 0 and 5 years of age. It was associated with an increase in the number of repeat visits per patient. The use of a more intense treatment in the emergency observation unit was associated with a reduction in the hospitalization rate for asthma.